Over the past 2 decades, research has shown that nursing homes can be noisy environments (Bharathan et al., 2007; Joosse, 2011; McClaugherty et al., 2001). Telephones, televisions, loud voices, and cleaning equipment can all be heard at a typical nursing home facility (McClaugherty & Burnette, 2001), where elevated noise levels are not only present during daytime hours, but also at nighttime (Schnelle et al., 1999). Sleep interruption among residents in nursing home facilities has been associated with medical (e.g., sleep-related respiratory disturbance, depression), environmental (e.g., noise, light) and behavioral (e.g., inactivity, excessive napping) factors (Schnelle et al., 1999). Nursing home staff have indicated that elevated noise levels have increased their heart rate and negatively impacted their mood and quality of work (McClaugherty et al., 2000). Conversely, Choiniere (2010) suggested that nurses may not always be able to identify potential risks associated with noise on their own health.
Studies have examined measured noise levels in nursing homes by sources, time, and location. McClaugherty et al. (2001) sampled noise levels in nine long-term care facilities and found the loudest fixed sounds in these facilities were open-door alarms (115 to 124 dBA), cleaning equipment (80 to 85 dBA), call lights (72 to 95 dBA), and telephones (72 to 95 dBA). Bharathan et al. (2007) measured noise levels of nurses' stations and patients' rooms in a nursing home affiliated with an urban community teaching hospital, and found that mean levels of noise were higher during morning and evening hours (58.9 dBA), compared to mid-day (56.5 dBA). Higher mean noise levels were noted at the nurses' stations (58.8 dBA) compared to patients' rooms (56.5 dBA), and human factors (e.g., conversations, visitors, telephones) were a major source of noise. Joosse (2011) examined mean noise levels during the day in the dining room, bedroom, and shared areas of four nursing homes in the Midwest, and found that the bedroom was the quietest location (51.94 dBA) and the dining room the loudest (60.43 dBA). The three loudest times of day were during dinner (59.46 dBA), after dinner (58.90 dBA), and after lunch (58.68 dBA). Approximately 25% of sound was generated from staff talking, although only 3% was directed at residents.
Other studies have compared perceptions of noise levels by staff with measured noise levels to gain an understanding of the impact of noise on residents and their care. McClaugherty et al. (2000) measured noise levels in 13 long-term care facilities and surveyed 135 nurses to examine the psychological and physiological effects of noise on staff. Identified noise sources and associated mean noise levels recorded at six of the long-term care facilities included: cleaning equipment (83 dBA), telephones (82 dBA), yelling by residents or staff (75 dBA), and normal conversation (73 dBA). Staff reported headaches (47%) and an increased heart rate or skin flushing (32%) from a noisy environment. Staff also said a noisy environment affected their job performance, with reports of feeling irritable (67%), anxious (53%), or having difficulty concentrating (64%). Seventy percent of nurses on staff reported it was “easier to make errors in daily job responsibilities in a noisy environment” (McClaugherty et al., 2000, p. 99). The major noise source in a study on medication use in long-term care environments was the nurses' station (McClaugherty & Burnette, 2001). Although no cause and effect were determined between noise and medication use, staff identified noise as a factor affecting the health and well-being of residents, directly and through effects on their own job performance.
Although no recent studies were found in the research literature comparing staff perceptions with measured noise levels in nursing homes, White and Zomorodi (2017) compared perceptions of critical care nurses to measured noise levels in an intensive care unit (ICU) at six academic health center hospitals. The Familiar Noise Sources Survey was completed by a random sample of 108 nurses who were asked to choose the noise source example that best described their perception of the current noise level in the ICU. Noise levels were measured prior to survey administration using the Decibel 10th iPhone® application, rather than a professional sound level meter. ICU nurses perceived noise levels within the unit to be higher than measured noise levels.
Although there are no regulations specific to nursing homes, the Environmental Protection Agency (EPA; 1974) has established noise exposure guidelines for hospitals to protect public health and welfare. An average sound level of 45 dBA during the day (7 a.m. to 10 p.m.) and 35 dBA at night (10 p.m. to 7 a.m.) is recommended in the hospital environment to prevent activity interference and annoyance. An EPA press release on April 2, 1974 (para. 3), indicated that these noise levels “permit spoken conversation and other activities such as sleeping, working and recreation, which are part of the daily human condition.” These hospital recommendations may be applicable to nursing home environments.
In nine facilities examined by McClaugherty and Burnette (2001), an average noise level of 76.7 dBA (range = 60.6 to 84.6 dBA) exceeds EPA recommendations. Bharathan et al. (2007) recorded noise levels that also exceeded EPA recommended limits (e.g., nurses' station mean noise level of 58.8 dBA). Joosse (2011) concluded that, overall, noise levels in nursing homes were higher than recommended for other health care organizations, such as hospitals (e.g., dining room mean noise level of 60.4 dBA). Findings from these studies indicate that high noise levels in nursing home facilities might be a stressor for residents and staff.
Despite a recommendation by McClaugherty et al. (2001) that a focus be placed on reduction of ambient noise in nursing homes, these environments continue to be noisy. In addition, there are no recent studies comparing perceived and measured noise levels in nursing homes, particularly since the implementation of a number of changes that could affect noise. In November 2017, the Centers for Medicare & Medicaid Services (CMS) discouraged the practice of overhead paging and piped in music in long-term care facilities that they certify, including nursing homes. In Ohio, the use of overhead paging systems in nursing homes was banned on July 1, 2015, unless it is for urgent public safety announcements or urgent clinical operations (Lassman et al., 2014). Finally, traditional institutional settings with multi-bed rooms, long corridors, and multi-purpose dining/activity rooms have been replaced by more home-like designs with smaller groupings of residents or “households” (Calkins, 2009). The purpose of the current descriptive study was to examine differences in nursing home staff's perceptions of noise levels compared to measured noise levels by sources, time, and location in four nursing homes in Ohio.
Noise data were collected from a convenience sample of four Medicare and Medicaid–certified nursing homes with varying designs in northwest Ohio. Five dosimeters were concurrently used to collect noise level data from five occupied areas inside each facility. Monitored sampling locations included the nurses' station, dining room, community space, resident room, and one additional space, such as an activity/common space or hallway, depending on the facility. The areas assessed were representative of where nursing home residents in other studies have experienced elevated noise levels (Bharathan, 2007; Joosse, 2011; McClaugherty & Burnette, 2001).
Facility A was built in a suburban area in 1992 (remodeled in 2015) and is laid out in a square. Thirty-two resident rooms are located along the outer walls with common spaces and the main nurses' station more centrally located. A smaller staff area is near the community space. At Facility B, which was constructed in 1966 in an urban area, a centralized nurses' station is located near a community space at one end of the nursing home. Most of the 54 resident rooms line the outer walls of a long hallway. Another community space is next to the dining room. Facility C was built in 2001 in a suburban area and has a centrally located nurses' station with wings extending in four directions. Eighty-one resident rooms are located along the outer walls in three of the wings and the dining room is in the fourth wing. The community space is an open area near the nurses' station. Constructed in a rural setting in 2001, Facility D has a centrally located nurses' station and abuts one community space. Pod areas with vaulted ceilings are present in the two wings associated with the nursing home and include a satellite kitchen, another community space, and dining room. Fifty-two resident rooms are in the pods and throughout the connecting hallway.
Noise in five areas was measured using factory-calibrated personal dosimeters (Spark Model 705+ Noise, 706RC, Larson Davis, Inc., NY). A standard noise calibrator (CAL150, Larson Davis, Inc.) was used to calibrate the dosimeters each sampling day. Noise data were collected on 2 weekdays and 1 day on the weekend, for a total of 3 days at each facility. Dosimeter microphones were placed on tripods, four feet above the ground, centrally located in each area. Dosimeters logged data for approximately 24 hours at 1-minute intervals on each of the days. At the end of each sampling event, the dosimeters were removed and the data downloaded for subsequent analysis.
Walkthroughs were done at each facility to identify noise sources that may be contributing to overall noise levels. Subsequently, noise generating source levels (e.g., television, alarms) or activities (e.g., talking) were measured with a factory-calibrated 3M SoundPro DL-2 (3M, Maplewood, MN)). The sound level meter was calibrated daily (AC-300, 3M). Each identified source was measured a minimum of three times (20 second average) and averaged.
Noise Perception Survey
A survey on perceptions of noise levels and physiological and psychological health effects was distributed to employees from the nursing homes after noise measurements were taken. Participants included health care staff, such as nurses, nurses' aides, therapists or social workers, as well as staff from other positions, such as housekeeping and office personnel who were at least 18 years of age. Survey questions were adapted from an instrument by McClaugherty et al. (2001). The revised instrument was verified for face and content validity by members of the research team. Three of the authors and members of this team are professionals with years of experience in caring for persons with dementia and their families or have expertise in environmental and occupational health. The survey was also distributed to a convenience sample of five individuals not participating in this study who reviewed it for readability and understandability. All team members collaborated to review and finalize the survey.
Participants were asked to rate noisemakers (e.g., television, call bell) in their nursing home using a scale ranging from 1 (very noisy) to 5 (quiet). Participants were also asked to rate, on a scale ranging from 1 (strongly agree) to 5 (strongly disagree), the physiological (e.g., increased heart rate) and psychological (e.g., anxiety) effects of noise levels in the facility in which they work, as well as whether they think noise levels affect residents' well-being. Finally, participants were asked to identify the noisiest times and locations within the facility and provide any recommendations for reducing noise levels.
Following Institutional Review Board approval, the administrative director at each facility was provided with envelopes containing a cover letter explaining the study and the survey to be distributed during regularly scheduled employee meetings. Participants were asked to stay 10 minutes extra to complete the survey or take it home and return the completed survey in a sealed envelope to the nursing home administrator. Completed surveys were picked up at a later date at all four locations. Participants' consent was implied by completion of the survey. Survey data were entered into SPSS 25. Descriptive statistics were used to analyze data.
Ninety staff members completed surveys. Most staff at all facilities were female, and consequently, so were participants in the current study (88.5% to 95.5% female). Mean age of participants ranged from 35 to 44 years old. Participants were also primarily White or Black, not of Hispanic origin; nurses, state-tested nursing assistants, administrators, or office staff; and had a degree, certificate, or special training. Demographics of the current study participants (N = 90) do not significantly differ in comparison to demographic data from the latest National Nurse Assistant Survey (Centers for Disease Control and Prevention, 2004). Table 1 provides the complete demographic profile for participants at each of the facilities.
Participant Demographics (N = 90)
Overall Noise Level
Survey participants indicated that all four facilities were moderately noisy. This finding was consistent with measured noise levels for daytime (62.9 to 63.3 dBA) and nighttime (61.2 to 62.4 dBA) hours in each facility.
Table 2 provides a summary of noise sources by facility and the associated average noise level (dBA). The percentage of participants who reported sources as noisy or very noisy are combined and also included. The loudest perceived sources of noise were similar to the sources with the highest measured noise levels in all facilities and included vacuum cleaners, floor buffers, and carpet cleaners, as well as patient and door alarms.
Noise Sources by Facility
Mean noise levels (dBA) over time in each facility are presented in Figure 1. These data were averaged over all locations in the facilities. Most participants stated that meal times were one of the noisiest times in all facilities (Facility A = 40%; Facility B = 33.3%; Facility C = 26.1%; and Facility D = 43.5%). Participants at two of the four facilities also reported personnel shift change as a time that noise levels were high (Facility B = 38.9% and Facility D = 43.5%). Measured noise levels demonstrated elevations during these times as well.
Mean noise levels by facility of all locations over time.
Table 3 presents measured noise levels for each location in the facilities as well as the percentage of participants who indicated this was the noisiest location. The nurses' station (21.4%), community space (21.4%), and dining room (28.6%) were reported by participants at Facility A as the noisiest locations. The reasons participants gave for these locations being noisy included that they were areas where large groups of people tended to gather for activities, staff members worked with residents, maintenance activities were performed, and there were televisions present.
Noisiest Locations in Each Facility
Participants from Facilities B and C reported the nurses' station (41.2% and 45.5%, respectively) and hallway (41.2% and 22.7%, respectively) as the noisiest locations. Facility B participants thought the reasons for noise around the nurses' station was that it is a place where everyone gathers, and shift changes, alarms, as well as telephone calls occur. The hallway was thought to be noisy because it is also an area where people tend to gather. Participants from Facility C thought the nurses' station was noisy due to ringing telephones and nurses talking on the telephones, as well as a number of people in the area communicating with one another.
Facility D participants perceived the kitchen (33.3%) and dining room (27.8%) to be the noisiest locations due to meal preparation and service, music playing, and various other activities that occurred in these spaces. Although three of the four facilities identified the nurses' station as one of the noisiest locations, this was inconsistent with measured noise levels. The dining room had high levels of measured noise, which was consistent with perceptions of noise levels. Measured noise levels were highest in the resident rooms and activity/common spaces.
Effects of Noise on Staff and Residents
The percentage of survey participants who agreed or strongly agreed to the physiological and psychological impacts of noise levels in their work environment and the effects on residents' well-being are combined and presented in Table 4. The three impact statements of a noisy environment with the highest percentage of participants strongly agreeing or agreeing were (a) it was easier to make errors, (b) feeling irritable/agitated, and (c) difficulty concentrating on work. Overall, however, participants at each facility were neutral or disagreed that noise levels impacted themselves or residents.
Comparison of Impacts of Noise Levels
Nursing home staff described the facilities as being moderately noisy, which was consistent with measured noise levels. These levels are well above the recommended EPA guidelines for indoor hospital environments. Although the indoor hospital environment may be different than the nursing home environment, no guidelines exist for nursing homes. Three of the four facilities identified the nurses' station as one of the noisiest locations; however, this was inconsistent with measured noise levels. Nurses' stations tend to be areas where people congregate, and previous research has found it to be a noisy location within nursing homes (Bharathan et al., 2007; McClaugherty & Burnette, 2001), and consequently, staff may be biased in their perceptions. Many facilities in this study were specifically remodeled or constructed with newer designs to reduce noise generated from nurses' stations (e.g., enclosing the nurses' station in a glassed-in room). Consistent with previous research (Joosse, 2011) and staff perceptions, measured noise levels in the current study indicated that the dining room was one of the noisiest areas. Contrary to other studies, the resident room had elevated noise levels, perhaps due to noisy ventilation systems, talking, or high television volumes in a small space.
Noise levels were perceived to be highest at meal times in all facilities. Measured noise levels also demonstrated elevations during these times. In interviews with health care providers for their perceptions of noise in nursing homes, McClaugherty et al. (2001) stated a dietician commented that during mealtimes, noise affected residents' ability to concentrate. Joosse (2011) also found that measured noise levels were elevated during dinner.
The loudest perceived sources of noise were similar to sources with the highest measured noise levels and included door/patient alarms, floor buffers and vacuum cleaners, as well as residents and staff. According to the noise impact survey by McClaugherty et al. (2000), staff rated cleaning equipment (e.g., vacuums, steam cleaners, floor buffers), auditory communication systems (e.g., intercom systems, call bells, alarms, phone systems), as well as medical staff, as the loudest noise sources. In contrast, staff in the current study perceived the intercom system as the quietest source. This perception could be due to the fact that nursing homes in Ohio are prohibited from using overhead paging systems (Lassman et al., 2014).
Overall, staff at all facilities were neutral or disagreed that they or the residents were impacted by a noisy environment. Participants in the current study perceived less of an impact related to a noisy environment than the survey participants in the study by McClaugherty et al. (2000). These results may be due to staff's inability to identify their own health risks as indicated by Choiniere (2010), or that they were surveyed after overhead paging was discouraged and more home-like nursing home designs were implemented. Some staff, however, agreed that in a noisy environment it is easier to make job errors, difficult to concentrate on work, and they find themselves irritable or agitated. Perceptions of noise should be considered along with measured noise levels because tolerance levels differ among individuals, and mental activities involving memory or complex analysis have been found to be sensitive to noise (Berglund et al., 1999). Consequently, job performance of staff, and ultimately quality of care provided to residents, could be affected.
Strengths and Limitations
Although this study was limited to four nursing homes in Ohio, a strength is it has implications for the continued focus on the reduction of noise in nursing home facilities. The results are generalizable because the sample of facilities and the sample of staff are representative of other Medicare and Medicaid–certified nursing homes in the United States. Environmental interventions could include replacing audible with vibrating alarms, installing soft door closers, and removing rubber transitions between carpet and tile flooring. Behavioral strategies include turning down or off television and phone volumes or using headphones, designating report areas away from resident rooms, and implementing quiet times (Connor & Ortiz, 2009). Noise reduction interventions and strategies must be targeted to a specific facility and location, however, and staff and residents should be consulted to find out where noises are coming from and to determine what steps can be taken to minimize as many extraneous sources of noise as possible. A limitation of this study is that residents were not surveyed about noise levels so their perspectives are unknown. Regardless, noise reduction interventions and strategies have benefits for the well-being of residents and staff in nursing homes.
Nurses are in a unique position to institute change by leading noise-reducing interventions, participating in teams to design new units or redesign existing units, and influencing shared-governance councils to change policy and practice. However, reasons for making and sustaining change must be meaningful to nurses and administrators for continued engagement and success in noise-reduction strategies (Watson et al., 2015). Therefore, efforts must be made to improve nurses' knowledge of the effects of excessive exposure to noise. Education on the adverse impacts of excessive noise on residents' and staff's health and performance is lacking. Without an improved understanding of the risks of noise exposure, reduction efforts will have little or no effect on lowering noise levels.
Nurses, administrators, and other employees of nursing homes should receive in-service training or continuing education on how elevated noise levels can lead to agitation and disturbed sleep in residents, and cause annoyance and poor job performance in staff. Staff need to learn to be mindful of when they are creating excessive noise, especially when residents could be sleeping. Visiting families should also be reminded to be quiet and to talk in residents' rooms, not hallways. Although these facilities are places of employment, staff should appreciate that they are primarily the residents' home.
Noise levels in four nursing homes in northwest Ohio exceeded the EPA noise exposure guidelines for hospitals during the day and at night. The dining room and nurses' station were commonly reported as noisy locations at all facilities, although measured noise levels indicated the resident rooms and activity/common spaces were the noisiest. The noisiest times reported and observed were during meal times and shift changes. Although staff did not perceive any major impacts due to noise levels, they need to be cognizant about how they contribute to these noise levels. Education about potential effects of noise on work performance and the quality of care provided to residents is also critical.
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Participant Demographics (N = 90)
|Facility A (n = 17)||Facility B (n = 22)||Facility C (n = 25)||Facility D (n = 26)|
| Female||16 (94.1)||21 (95.5)||23 (92)||23 (88.5)|
| Male||1 (5.9)||1 (4.5)||2 (8)||3 (11.5)|
| White, not Hispanic||10 (62.5)||17 (77.3)||18 (75)||17 (65.4)|
| Black, not Hispanic||4 (25)||5 (22.7)||4 (16.7)||6 (23.1)|
| Hispanic||1 (6.3)||0 (0)||1 (4.2)||0 (0)|
| American Indian or Alaskan Native||1 (6.3)||0 (0)||0 (0)||0 (0)|
| Asian or Pacific Islander||0 (0)||0 (0)||0 (0)||1 (3.8)|
| Other||0 (0)||0 (0)||1 (4.2)||2 (7.7)|
|Degree, certificate, or training|
| Yes||16 (94.1)||20 (90.9)||19 (76)||20 (83.3)|
| No||1 (5.9)||2 (9.1)||6 (24)||4 (16.7)|
|Job within facility|
| State-tested nursing assistant/nurse aide||11 (64.7)||4 (18.2)||7 (28)||15 (57.7)|
| Office staff/administrator||4 (23.5)||11 (50)||1 (4)||4 (15.4)|
| Therapist||1 (5.9)||4 (18.2)||6 (24)||1 (3.8)|
| Cook/kitchen staff||1 (5.9)||0 (0)||3 (12)||1 (3.8)|
| Housekeeping/maintenance||0 (0)||2 (9.1)||0 (0)||1 (3.8)|
| Nurse||0 (0)||1 (4.5)||7 (28)||4 (15.4)|
Noise Sources by Facility
|Noise Source||Average Noise Level (dBA)||Noisy and Very Noisy Rating (%)|
|Facility A (n = 17)|
| Vacuum cleaner||72.5||37.2|
| Patient/door alarms||65.7||37.5|
| Talking residents||59.8||13.3|
| Talking medical staff||59.8||6.3|
| Floor buffer, carpet cleaner||NA||26.7|
|Facility B (n = 22)|
| Floor buffer, carpet cleaner||68.7||36.4|
| Talking medical staff||60.7||36.4|
| Talking residents||60.7||36.3|
| People on phones/ringing||56.6||28.6|
| Patient/door alarms||56||31.8|
|Facility C (n = 25)|
| Floor buffer, carpet cleaner||73.1||32|
| Talking medical staff||62.2||16|
| Talking residents||62.2||16|
| People on phones/ringing||NA||28|
|Facility D (n = 26)|
| Vacuum cleaner||74.2||24|
| Floor buffer, carpet cleaner||74.2||20.8|
| Patient/door alarms||72.3||37.5|
| Talking residents||56.7||16|
| Talking medical staff||56.7||3.8|
| Call bells/pages||NA||36|
Noisiest Locations in Each Facility
|Facility Locationa||Participants Indicating Noisiest Location, n (%)||Mean Noise Level (SD) (Range) (dBA)|
|Facility A (n = 17)|
| Dining room||4 (28.6)||64.5 (1.1) (61.9 to 73.8)|
| Nurses' station||3 (21.4)||57.8 (3) (53.4 to 73)|
| Community space||3 (21.4)||57.6 (3.8) (51.1 to 75.6)|
| Activity/common space||2 (14.3)||NA|
| Hallway||1 (7.1)||65.6 (0.9) (63.9 to 80.1)|
| Kitchen||1 (7.1)||NA|
| Resident room||NA||65.9 (2) (62.6 to 76.6)|
|Facility B (n = 22)|
| Nurses' station||7 (41.2)||59.4 (4.1) (52.6 to 78.4)|
| Hallway||7 (41.2)||NA|
| Dining room||2 (11.8)||63.6 (2.6) (60 to 82.7)|
| Community space||1 (5.9)||57.6 (3.4) (50.1 to 81.1)|
| Activity/common space||0 (0)||66.5 (1.1) (65.1 to 99.8)|
| Kitchen||0 (0)||NA|
| Resident room||NA||66.7 (1.4) (64.4 to 74.4)|
|Facility C (n = 25)|
| Nurses' station||10 (45.5)||60.6 (3.5) (54.1 to 80.1)|
| Hallway||5 (22.7)||NA|
| Dining room||3 (13.6)||63.1 (2.1) (61 to 83.4)|
| Community space||2 (9.1)||59.5 (1.8) (56.5 to 76.1)|
| Kitchen||1 (4.5)||NA|
| Activity/common space||0 (0)||63.7 (5.5) (54.4 to 98.2)|
| Resident room||NA||66.7 (1.1) (64.2 to 88.1)|
|Facility D (n = 26)|
| Kitchen||6 (33.3)||NA|
| Dining room||5 (27.8)||62.3 (1.7) (59.8 to 74.3)|
| Community space||3 (16.7)||60 (2.2) (57.2 to 73.2)|
| Nurses' station||3 (16.7)||58.5 (3.7) (52.3 to 86.4)|
| Activity/common space||0 (0)||67.6 (0.4) (65.4 to 75.8)|
| Hallway||0 (0)||NA|
| Resident room||NA||66.5 (1) (64.5 to 73.7)|
Comparison of Impacts of Noise Levels
|Statement||Agree and Strongly Agree Rating (%)|
|Facility A (n = 17)||Facility B (n = 22)||Facility C (n = 25)||Facility D (n = 26)|
|I find myself to be anxious when I am in a noisy environment||25||27.2||20.8||19.2|
|It is difficult to concentrate on my work because of high noise levels||18.8||40.9||33.4||30.8|
|I find myself to be irritable or agitated when I am in a noisy environment||18.8||31.8||33.3||19.2|
|In a noisy environment, it is easier to make errors in daily job responsibilities||17.7||45.4||32||24|
|I often get headaches when I am in or have been in a noisy environment||12.6||18.1||12.5||19.2|
|I can feel my heart beating faster or get flush when I am in a noisy environment||6.3||27.3||8.3||16|